Provider Demographics
NPI:1093886269
Name:MALONE, DWIGHT WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:WAYNE
Last Name:MALONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4201 TORRANCE BLVD
Mailing Address - Street 2:STE 790
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-4561
Mailing Address - Country:US
Mailing Address - Phone:323-779-2800
Mailing Address - Fax:323-754-4014
Practice Address - Street 1:4201 TORRANCE BLVD
Practice Address - Street 2:STE 790
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4561
Practice Address - Country:US
Practice Address - Phone:323-779-2800
Practice Address - Fax:323-754-4014
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG71749207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOG717490Medicaid
CAF63990Medicare UPIN
CAW13017Medicare ID - Type Unspecified
CAOOG717490Medicaid